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  EDITORIAL 100 Years After the Flexner Report Reflections on Its Influence on ChiropracticEducation When the American Medical Association (AMA)began in 1847, one of its primary intentions wasto improve medical education. 1 At this time therewas disagreement among both educators and practi-tioners as to how medical doctors should be taughtand how diplomas should be granted. Some arguedthat the course of medical education, which weighedheavily on an apprenticeship model, was too shortand needed to be increased. “These resolutionsdeclared a  four   months college term  too  short foran adequate course of lectures on all the branches of medical science, and the standard of education, bothpreliminary and medical, required by the schoolsprevious to the granting of their diplomas, alto-gether too low; while the union of the teaching andlicensing power in the college faculties was repre-sented as impolitic, and constantly liable to abuse.” 1 As well, there was a call for greater standards inthe approach to medical education. Davis writes,“The standard of preliminary or preparatory  educa-tion  should be greatly elevated, or, rather, a  standard  should be fixed, for there is none now, either intheory or in practice.” 1 At this time, medicine had not yet become ascience-based profession. The practice of “regular”medicine was based on “ . . . bloodletting, purging,(and) emetics,” 2 medical procedures that are nowrecognized as causing patients more harm thangood. 3 Concurrently, there was a movement inAmerica to embrace science as the solution tomany problems facing the world. 4 This scientific The Journal of Chiropractic Education Copyright © 2010 Association of Chiropractic Colleges Vol. 24, No. 2. Printed in U.S.A.1042-5055/$22.00 movement would help to drive the medical reformthat the Flexner report would later demand.Thought to have begun in 1895, chiropracticprovided a holistic and drugless alternative to themethods that medicine offered to achieve health. Itwas in 1897 that Daniel David Palmer, chiropractic’sfounder, first advertised teaching his method of healing. Chiropractic was to be taught at the Schoolof Magnetic Cure “for the purpose of teaching howto get well and keep well without taking poisonousdrugs.” 5 In these early years, the term of instruc-tion was 3 months and was based primarily onan apprenticeship method of training. Similar tomedicine, after a course of instruction, diplomaswere granted confirming that the recipient wastrained in chiropractic. At this time, chiropracticwas only a fledgling group of practitioners, not aprofession. It had no organizational structure anddid not have governmental or other external support.In its first 10 years, only a handful of schoolswere producing chiropractic graduates and an educa-tional curriculum had not yet formally been devel-oped. Though new chiropractic schools sprang upin just a few years, they were primarily proprietaryin nature, thus competing against each other insteadof collaborating. 5 Similar to most medical schools,the chiropractic curricula in the late 1890s were notbased in science. Whether or not the chiropracticeducators and advocates at the time were aware,chiropractic was heading on a collision course withthe reform of organized medicine.Just before the turn of the century, medical educa-tion was still struggling with identity and standard-ization. Medical schools were in a state of disarray.Medical programs were proprietary in nature with The Journal of Chiropractic Education,  Vol. 24, No. 2, 2010 145  a primary motivation for personal financial gaininstead of professional advancement. Standards werestill not common among the medical schools andsome thought the standards for students to enter theschools were still too low. Science was not includedin the medical programs and some were slow to tran-sition away from the traditional methods of purgingand bloodletting. Much needed to transpire beforemedicine would become the juggernaut of the 20thcentury.Berliner states that “The institutionalization of scientific medicine began in the United States in1893 with the opening of the Johns Hopkins MedicalSchool.” 4 By 1901, when the Rockefeller Institute of Medical Research was formed, Johns Hopkins wasstill the only medical school in the United Statesthat taught students using the scientific method. 4 As science was being embraced in medical educa-tion, there was a greater focus on the causationof disease. With this transition, unfortunately theconcepts of whole-body health and healing began todisappear. Any profession that may have focused ona holistic approach, such as chiropractic, may havebeen marginalized in this environment. According toBerliner 4 : With the new paradigm of scientific medicine,the body began to be conceptualized in termsof systems unrelated to other systems of thebody. And although specialization had beenpresent in the context of whole-body medicine,specialization under scientific medicine began toemphasize individual systems or organs to theexclusion of the totality of the body. The embrace of scientific medicine may have beenone of several reasons that medical curricula frac-tioned the study of medicine into systems and partsinstead of honoring the patient as a whole.In the early 1900s, chiropractic was still attemptingto obtain a foothold in its method, cultural accep-tance, and approach to education. Some chiropracticschools began to offer correspondence courses, whichD.D. Palmer, among others, strongly criticized. Incontrast, some other chiropractic programs werelengthening their didactic education and evidenceof basic sciences and broadened clinical treatmentmethods were seen in advertisements for theirprograms. For example, founded in 1903, the Amer-ican School of Chiropractic and Nature Cure is cred-ited with developing the first structured curriculumconsisting of 4 terms of 5 months each. 5 The PalmerCollege of Chiropractic in Portland, founded in1908, advertised that it offered 2 years (9 monthsper year), which included “ . . . minor surgery, obstet-rics, forensic jurisprudence, and a full course of dissection.” 5 Although it is not clear how similarthese programs were compared to some of themedical schools at the time, the environment inthe pre-Flexner report era left many health careprograms to govern themselves, since standards werestill being developed. Unfortunately, what growthwas present in chiropractic education was neithercoordinated nor could it keep up with the trends thatthe medical profession was beginning to address inan organized manner.Even though the AMA was developing a stronginfluence in cultural authority in the United States,there was dissatisfaction among the AMA leadersabout the state of medical education. In 1904, theAMA created the Council on Medical Education(CME). The CME performed periodic evaluationsof medical schools that had minimal consequences.In 1909, the CME published a model medicalcurriculum. 2 The curriculum that they recommendedhad a total of 4100 hours; 1970 of these were focusedon the basic sciences. According to Barzanskyand Gevitz, 2 although the medical curricula lookedsimilar on paper, “It was in the amount and qualityof lab teaching that they differed most markedly.”However, there was not enough impetus to makechanges from within the medical profession; thus,the AMA searched for a strong imposing force fromthe outside to facilitate the change. 3 , 4 In 1908, the AMA’s CME proposed to the CarnegieFoundation a study on medical education with thehopes of gaining greater influence in this processand “to hasten the elimination of medical schoolsthat failed to adopt the CME’s standards.” 3 TheCarnegie Foundation hired Abraham Flexner, aneducational theorist, 3 to complete the study. Flexnerhimself was not medically trained nor was he trainedas a researcher; instead he received a bachelor’sdegree from Johns Hopkins and was thus consid-ered a layman. 4 The CME gave Flexner the datathat they had been collecting on medical schoolsprior to his study, which may have biased his report. 2 In less than 2 years, Flexner observed 155 institu-tions of medical education in the United States andCanada and drafted his report. He relied on manydocuments generated from the AMA and it is notcertain how much influence the AMA had in thedrafting of the final version of his study. 2 In 1910,Abraham Flexner’s report,  Medical Education in theUnited States and Canada: A Report to the CarnegieFoundation for the Advancement of Teaching , was 146 Johnson and Green: Editorial  © 2010 Association of Chiropractic Colleges  published with the intention of transforming medicaleducation. 6 Most would agree that his report accom-plished, or at least influenced, this goal.Flexner’s report included harsh evaluations of the majority of medical schools at the time. Hiscomments ranged from criticizing the schools’ pro-prietary nature that generated an overabundance of ill-educated doctors who risked the health of thepublic, to the lack of adequate training and poorscientific foundation. “Men get in, not because thecountry needs the doctors, but because the schoolsneed the money”and “ . . . it is idle to talk of1 reallaboratory work for students so ignorant and clumsy.Many of them, gotten through advertising, wouldmake better farmers.” 6 Barzansky and Gevitz summarize the seven majorrecommendations that Flexner included in his report 2 :1. To reduce the number of poorly trained physi-cians;2. To reduce the number of medical schools from155 to 31 (by the time the report was publishedschools had already decreased to 131);3. To increase the prerequisites to enter medicaltraining;4. To train physicians to practice in a scientificmanner;5. To engage the faculty in research;6. To have medical schools control clinical instruc-tion in hospitals; and7. To strengthen state regulation of medical licen-sure.Flexner’s primary emphasis on the structure of amedical curriculum was the first 2 years focusingon basic sciences followed by 2 years of clinicalstudies. However, other topics were described inthe report, including descriptions of what he feltthe ideal program should include, discussion of theethical responsibility of hospitals to focus on patienthealth instead of doctors’ financial prosperity, post-graduate education programs that transform them-selves from being tools to fix incompetent doctors toproviding advanced education, and the instrumentalrole of state boards in transforming medical educa-tion. The transformation extended to many areas of health care education. Whether these were intendedor unintended consequences, most agree that thechanges were dramatic.Barzansky and Gevitz suggest that some haveoverstated the importance of the Flexner report sincemedical education reform was progressing evenbefore Flexner’s project began. 2 Thus, Flexner’sreport merely helped to consolidate a desired butalready occurring process to improve medical educa-tion and practice. They suggest that 2 His most significant accomplishments were inhelping to take away control of hospitals andof medical education, especially clinical educa-tion, from the practicing medical profession andto bring it under the authority of academicbureaucracy, and in raising, at least in sciencesubjects, the intellectual and academic require-ments for medical school matriculation. Surelythese things were going to happen as a conse-quence of multiple factors already in motion, butFlexner was able to crystallize them, to makethem coalesce, to focus them into a recogniz-able movement with direction and momentum,and to shape the form of clinical education forthe years that followed. The Flexner report seemed to have a substantialimpact on medical schools. Within 20 years afterthe report’s publication, the original 131 medicalschools from 1910 were reduced to 76, althoughnot 31 as Flexner srcinally suggested. There wasa decrease in graduates but this trend reversed inthe following decades (Fig. 1, A and B). After thereport, there was an increase in basic sciences andlaboratory courses, and increased requirements forstudents entering school. Entrance requirements alsoevolved during the first third of the century. In1904 more than 95% of the medical schools onlyrequired a high school education to enter. By 1929,100% of all medical programs required at least 2years of college education. 2 Although many medicalschools closed after the publication of the report, thereport was only one of many factors. 7 Other factorsmay have included the AMA’s efforts to controlhealth care through political methods and licensinglaws. 7 State licensing board exams were primarilybased on basic sciences and were designed to limitgraduates from nonscientific schools from becominglicensed. 4 , 8 Since licensing boards were controlledby the AMA, exams were designed to discriminateagainst nonmedical practitioners. This likely had anegative impact on those chiropractic programs thatwere in the initial stages of development at this time.The changes occurring after the report not onlyaffected medical education but also the law whichgoverned the practice of medicine and thereforeother health care practices. In the early 1900s,the medical practice laws were just beginning tobe modified and challenged by the chiropracticprofession. As the profession was being persecutedby those in medicine who were trying to protecttheir field of practice, legal and legislative changes © 2010 Association of Chiropractic Colleges  The Journal of Chiropractic Education,  Vol. 24, No. 2, 2010 147  AB Figure 1. (A) The initial decline but rise of medical students in North America from 1910 to 1930 (adapted  from Barzansky and Gevitz 2 ). (B) The decline in the number of medical schools in North America from 1910to 1930 (adapted from Barzansky and Gevitz 2 ). began to evolve that required recognition of theright to practice chiropractic. Oftentimes in orderto establish these rights, chiropractic was requiredto demonstrate that it was a separate and distinctprofession from medicine, with the theory thatdoctors of chiropractic should not be prosecutedfor practicing medicine without a license. As well,licensing laws were developed for various healthcare practices and would incorporate the princi-ples of the Flexner report, such as to include basicscience education. These changes in basic sciencerequirements and other criteria would transformchiropractic curricula. Up until these requirementswere put into place, many chiropractic programswere underdeveloped. Because of the changes inthe licensing boards, due to the Flexner report orother influences, chiropractic schools were pressedto change their curricula in order for their graduatesto be licensed in various states.In 1917, at the Palmer Lyceum, the first effortswere made to standardize chiropractic education. 5 This may have been an attempt to address theincreasing pressure from licensure laws through thechiropractic institutions. The International Associa-tion of Chiropractic Schools and Colleges (IACSC)was formed, with 19 member colleges. One of thepurposes of the IACSC was “ . . . to unify and stan-dardize the conceptions of Chiropractic leaders as towhat Chiropractic actually is, and to determine whatshould be conceived to be a standard Chiropracticeducation . . . ” 5 However, the IACSC did not lastlong, apparently due to lack of support and interest,though other educational organizations formed in itsplace in later years.Though the Flexner report is lauded by some asone of the most important transformational eventsin medical education in the last century, not alloutcomes from this document were necessarily posi-tive. There was a loss of support and a reducedobjective view of some of the other health profes-sions (ie, osteopathy, chiropractic, naturopathy) thatwere developing at the time. Since the study leading 148 Johnson and Green: Editorial  © 2010 Association of Chiropractic Colleges
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